An Open Letter To Insurance Companies

Dear Insurance Companies,

It has become increasingly apparent that there are some significant injustices when it comes to treatment coverage for individuals suffering from eating disorders. Though eating disorders have the highest mortality rate of any mental illness, a mortality rate that actually rivals that of some cancers, many of you, the insurance companies, have policies that specifically exclude reimbursement for eating disorders. As someone who has had to obtain treatment for my own eating disorder, and now years later, is working as a professional in an inpatient eating disorders treatment facility, I feel that I can offer a unique and multifaceted view on this managed care issue. Here are some of the main problems that I have noticed with the way that you deal with eating disorder coverage:

All too often, you provide very low caps, particularly on inpatient days. In fact, the number of inpatient days provided is often so shockingly low that it leaves me wondering if you have been educated as to what the purpose of an inpatient facility even is? What do you expect us, the psychologists, psychiatrists, and dieticians, to accomplish in five days? Perhaps it would be helpful for you to read through the DSM-5 and other accompanying literature, so that you may better comprehend the chronicity and stubborn nature of this illness.

Many of you will only cover expenses that are “medically necessary” but will not rule on medical necessity until well after treatment has been initiated. Then, ridiculously, upon review it is decided that care for an eating disorder is not deemed medically necessary. Once again, this leaves me wondering if you have been provided with the proper education needed to understand the nature of eating disorders. These illnesses often include a medical and psychological component. Both are serious enough to warrant treatment.

You tend to use weight as the defining factor in whether or not someone receives coverage. This is particularly problematic. I cannot begin to describe how much heartache this ill-thought-out notion has caused both myself in the past, and now the patients that I work with currently. For one thing, it provokes and provides fuel for the long-standing and stubborn “I am not sick enough to deserve help,” thought that plagues so many individuals with eating disorders. Secondly, it colludes with current societal ignorance that eating disorders must be accompanied by weight loss. Did you know that the vast majority of those suffering from eating disorders are not underweight? Please try to understand- you cannot tell who has an eating disorder by looking at them. Low body weight is a symptom of some (the minority) of those suffering from eating disorders. Can you now begin to see the absurdity of basing coverage on a symptom that most sufferers do not have? This would be like basing coverage for chemotherapy on headaches. Some people suffering from certain types of cancer might have headaches, but to base coverage on this transient symptom simply makes no sense

You seem to place a hierarchy of eating disorders that is not based in fact. For example, Anorexia Nervosa is typically considered easier to obtain coverage for than Eating Disorder Not Otherwise Specified. However, a 2009 Longitudinal study by Crow et al determines that there is an increased rate of mortality for Bulimia Nervosa and Eating Disorder Not Otherwise Specified. This new study shows that this diagnosis has an elevated mortality rate similar to that of Anorexia Nervosa. I urge you to read this research, in order to better understand that coverage should not be diagnosis-specific.

Some of your policies appear to base coverage entirely on medical necessity, with no regards to emotional or psychological symptoms. Hence even if you do take other factors (aside from weight) such as blood work into account, when these symptoms clear up, you decide to stop covering treatment. Again, this leaves me wondering if you understand the nature of eating disorders. To clear up some of your misunderstandings, I recommend that you read “The Great Starvation Experiment” for a research-based perspective on the long-lasting psychological effects of manipulating food intake and weight. Eating disorders do no “go away” once weight/blood pressure/ electrolytes have been stabilized. Please understand- pulling coverage as soon as medical symptoms have cleared leaves patients confused, and clinicians aggravated.

These, insurance companies, are the main problems that I have noticed thus far. Because treatment for eating disorders is so critical and can, quite literally, mean the difference between life and death, I urge you to begin to think more deeply and in a way that makes sense about coverage for these illnesses. Please hear my plea, and the pleas of sufferers, family members, friends, and clinicians all around the world. The request is quite simple. We want eating disorders to be covered by all insurance companies in the very same way that medical illnesses are. We want time and consideration placed into length of stay granted, and we want a deeper understanding about the nature of eating disorders by you, the people who are controlling the very treatment that will save our lives, and the lives of our patients.